Provider Demographics
NPI:1447312178
Name:ROARK, RANDALL ALAN (NP)
Entity type:Individual
Prefix:
First Name:RANDALL
Middle Name:ALAN
Last Name:ROARK
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1695 N SUNRISE WAY
Mailing Address - Street 2:
Mailing Address - City:PALM SPRINGS
Mailing Address - State:CA
Mailing Address - Zip Code:92262-3701
Mailing Address - Country:US
Mailing Address - Phone:760-323-2118
Mailing Address - Fax:
Practice Address - Street 1:1695 N SUNRISE WAY
Practice Address - Street 2:
Practice Address - City:PALM SPRINGS
Practice Address - State:CA
Practice Address - Zip Code:92262-3701
Practice Address - Country:US
Practice Address - Phone:760-323-2118
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-16
Last Update Date:2024-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA568148363LA2200X
CA15996363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORR0000WCJHTMedicare Oscar/Certification
ORR0000WCJHTMedicare Oscar/Certification
OR096511Medicaid